DRG Coding Advisor: Take these tips for preventing APC data quality gaps
DRG Coding Advisor: Take these tips for preventing APC data quality gaps
For HIM department, preparation is key
As HIM professionals continue to struggle with data quality issues embedded in Medicare’s Outpatient Prospective Payment System (OPPS) 18 months after the system went into effect, there are various lessons to be learned from early trials and errors.
First, HIM professionals need to know exactly what the terms mean.
"The term outpatient’ needs to be dissected more," says Cynthia Pugliese, MS, RHIA, CPHQ, director of health information management at Hartford (CT) Hospital. "When we’re talking about ambulatory surgery, it’s very different from the emergency room and diagnostic services, and you can’t have an outpatient process that speaks for all outpatient services."
One model won’t work for all, Pugliese says. "You have to look at distinct services and decide what makes the most sense."
Now, more than a year into OPPS, facilities that prepared for the implementation of OPPS are generally faring much better than those that did not, says Cheryl D’Amato, RHIT, CCS, director of HIM for HSS Inc. of Hamden, CT.
"Unfortunately, hospitals were not aware of the huge resource requirements that were necessary to implement the system and were not prepared for the quarterly changes that have occurred," D’Amato adds. "One of the major challenges hospitals must now address is evaluating the actual financial impact that OPPS has had."
For instance, Year 2 of OPPS should be focused on evaluating the impact of OPPS and putting processes in place to handle ongoing changes to the system, D’Amato says. (See "To improve quality data, HIM pros face challenges," in this issue.)
Pugliese and D’Amato spoke about improving ambulatory payment classification (APC) data quality at the American Health Information Management Association’s (AHIMA’s) 73rd National Convention and Exhibit, held Oct. 13-18, 2001, in Miami Beach.
One reason HIM staff should target outpatient services for a data quality initiative is that outpatient encounters are very short, leaving staff less time — typically less than one day — to clarify, verify, and edit data in the registration system and the medical record.
At Hartford Hospital, a back-end data scrubber checks APC coding data to ensure bills are correct before they are sent to Medicare, Pugliese says.
The data scrubber applies all coding edits and looks at the line-item charge information to make certain all charges will be reimbursable under Medicare guidelines, she explains.
For example, if the coding data for a particular lab charge indicate there were 26 units for the charge but Medicare says there are 25 maximum allowable units for the charge, the data scrubber would flag this for review. It will also edit for any instances of two CPT codes on the same bill, which may indicate bundling, Pugliese says.
Even when facilities cannot assign one position to data scrubbing, there are various strategies that will ensure cleaner and more accurate data under OPPS. Here are some of Pugliese’s suggestions:
1. Form a charge description master (CDM) committee.
Much of the data required under APCs can be found on the CDM, so Hartford Hospital formed a multidisciplinary CDM committee.
The committee’s role is to implement necessary changes to the CDM, according to a recent assessment conducted by an outside consultant. The committee will educate staff on how to maintain the CDM on an ongoing basis and will develop processes for adding, deleting, and modifying entries to the CDM, Pugliese says.
The committee includes representatives from HIM, finance, patient accounts, information services, and a clinical department representative.
"We focus primarily on the outpatient area right now, and we have a consultant help with this committee," Pugliese says.
The committee, founded last summer, meets every other week.
CDM committee educates staff
So far, the committee has drafted a process policy for ongoing CDM maintenance, and a committee point person has visited task forces throughout the hospital to discuss and educate staff about the CDM, Pugliese says.
The committee will continue to educate staff about the role each department plays in completing the CDM. At these educational sessions, committee members obtain feedback that is brought back to the committee.
2. Start a denials management group.
The hospital also formed a denials management group to understand the patterns and trends of outpatient claim denials, Pugliese says.
"We want to know why denials may be occurring and what we need to do to improve our data submission," Pugliese explains.
Like the CDM committee, this group also consists of representatives from HIM, finance, patient accounts, and the information services and clinical departments.
The committee will assess claims denials according to whether these types of denials have high volume, high risk, or high cost, and the group will establish processes to prevent denials from happening, Pugliese says.
Staff from patient accounts and finance collect the data about various denials, and then the committee will look at the aggregated facts, Pugliese explains.
For example, the hospital might have had 10 denials for the same reason in the emergency department. So the committee will notify the ED staff and give them a list of contact people in the HIM department who can be called whenever they have a question about a coding-related issue.
3. Hire an HIM coding consultant.
The hospital hired an HIM coding consultant to serve as a liaison with the clinical areas that complete encounter forms and to assist them with ongoing maintenance of encounter forms, Pugliese says.
"The consultant will educate staff about coding issues and will support their CDM maintenance as it relates to coding," she adds.
The consultant/liaison also can be the person who is called by other departments when there are coding questions and changes to regulations.
In addition, the hospital has instituted various audit cycles and compliance policies with regard to APCs, including the installation of an APC grouper with software that will enable HIM staff to examine edits in outpatient coding, Pugliese says.
4. Design process to improve APC data quality.
The finance department took the lead and developed an APC management report, but the report also was the result of input from patient accounts, HIM, patient registration, and clinical departments, Pugliese says.
Here are a few of the changes Pugliese suggests for improving the APC data collection process:
- Redesign the process. HIM professionals might define outpatient medical record types and corresponding documentation requirements, ensuring that similar services provided in multiple areas have the same documentation requirements.
- The process should define who documents each requirement and how.
- Hospitals should define in writing the scope and depth of the initial patient assessment for all patient types.
- The process should determine what documentation is required from referring physicians and in what format, including a definition of requirements for appropriate diagnosis for ancillary testing.
- The medical staff should be involved and educated on documentation policies.
5. Educate other departments about APCs.
"There has been a major cultural shift as a by-product of the APCs," Pugliese notes. "We have focused so long on inpatient coding and bill processing, but with the advent of APCs there was a shift, and now we have PPS with outpatient and a lot of other issues that have come to the top of the priority list."
At Hartford Hospital, for example, it has been an issue to define who owns CDM maintenance, Pugliese says.
"Many organizations have a function where the CDM sits in finance and it is a finance department thing," she says.
At Hartford Hospital, CDM maintenance is seen as a partnership between the clinical department and finance. HIM supplies coding expertise, and patient accounts supplies revenue codes and payer-specific information, Pugliese says.
"That’s a huge shift for clinical areas to understand that they are a driver in what charges are in the CDM," she adds.
This is why staff education is a crucial element of the process to improve data quality.
Each clinical department at Hartford Hospital has specific APC task forces that include a clinical department head as the team leader, as well as representatives from clinical, finance, HIM, and patient accounts. These task forces will range in size from four to 12 members and sometimes include nurses, directors, physicians, and clerical staff.
The HIM, finance, and patient accounts representatives educate other task force members about APCs, the CDM, and other data and coding quality issues. The task forces meet weekly, biweekly, or monthly, depending on the need.
"They talk about the process changes that may be needed to support the APC environment," Pugliese says.
Also, Pugliese suggests that all staff be educated on issues related to APCs, ICD-9-CM diagnosis codes, HCPCS codes, HCPCS modifiers, OCE edits, and NCCI edits. HIM professionals could provide this education in partnership with patient registration, patient accounts, and finance experts.
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